﻿<!--
	作者：344805262@qq.com
	时间：2015-11-02
	描述：商家报备
-->
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<html>
<head>
    <meta name="viewport" id="viewport"
          content="width=device-width, minimum-scale=1, maximum-scale=1, initial-scale=1.0,user-scalable=no" />
    <meta name="apple-mobile-web-app-capable" content="yes" />
    <meta name="apple-mobile-web-app-status-bar-style" content="black-translucent" />
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    <meta charset="utf-8">
    <title>商家报备提交申请</title>
    <link href="../../css/css.css?v=185" rel="stylesheet" type="text/css">
    <style type="text/css"> 
    	.divRegion select{ width:80px; }
    </style> 
</head>
<body>
<div class="header">
    <span id="back" class="headleft">
        <a class="back"><i class="iconfont icon-jiantou"></i></a>
    </span>
    <span class="tbbiaoti">提交申请</span>
    <span class="headright"></span>
</div>
<!----------------内容开始---------------------------->
<div class="main">
    <div class="bgbai mbtopbottom zitidx">
        <p class="tjren mbbottom">
            <a href="#">
        	<span class="wenbenkw">
        		<input id="creater" type="text" placeholder="申请人" class="tjsqwbk">
        	</span>
                <b>*</b>申请人
            </a>
        </p>
        <p class="gsbiaoti mbbottom">公司基本信息</p>
        <p class="tjren mbbottom mleft10">
            <a href="#">
        		<span class="wenbenkw">
        			<input id="name" type="text" placeholder="公司名称" maxlength="128" class="tjsqwbk">
        		</span>
                <b>*</b>公司名称
            </a>
        </p>
        <p class="tjren mbbottom mleft10">
            <a href="#">
	            <span>
                    <input id="supplier_industry" type="text" placeholder="所属行业" maxlength="128" class="tjsqwbk">
	            </span>
                <b>*</b>所属行业
            </a>
        </p>
        <p class="tjren1 mbbottom mleft10">
            <span class="divRegion">
	            <select class="sxhyxl" id="province">
	                <option value="0" selected='selected'>选择省</option>
	            </select>
	            <select class="sxhyxl" id="city">
	                <option value="0" selected='selected'>选择市</option>
	            </select>
	            <select class="sxhyxl" id="country">
	                <option value="0" selected='selected'>选择区</option>
	            </select>
            </span>
            <b>*</b>所在区域
        </p>
        <p class="tjren1 mbbottom mleft10">
            <a href="#">
    		<span class="wenbenkw">
    			<input id="address" type="text" placeholder="详细地址" maxlength="128" class="tjsqwbk">
    		</span>
                <b>*</b>详细地址</a>
        </p>
        <p class="tjren1 mbbottom">
            <a href="#">
				<span class="wenbenkw">
					<input id="phone" type="text" placeholder="公司电话" maxlength="128" class="tjsqwbk">
				</span>
                <b>*</b>公司电话
            </a>
        </p>
        <p class="gsbiaoti mbbottom">联系信息</p>
        <p class="tjren mbbottom mleft10">
            <a href="#">
        		<span class="wenbenkw">
        			<input id="chargeman_name" type="text" placeholder="公司负责人" maxlength="128" class="tjsqwbk">
        		</span>
                <b>*</b>公司负责人
            </a>
        </p>
        <p class="tjren mbbottom mleft10">
            <a href="#">
        		<span class="wenbenkw">
        			<input id="linkman_name" type="text" placeholder="联系人名称" maxlength="128" class="tjsqwbk">
        		</span>
                <b>*</b>联系人
            </a>
        </p>
        <p class="tjren mbbottom">
            <a href="#">
        		<span class="wenbenkw">
        			<input id="linkman_phone" type="text" placeholder="联系人电话" maxlength="128" class="tjsqwbk">
        		</span>
                <b>*</b>联系电话
            </a>
        </p>
        <p class="gsbiaoti mbbottom">补充信息</p>
        <p class="tjren1 mbbottom mleft10">
            <span class="xxlyxz">
				<span class="from-1">
                	<b class="checkboxFour">
						<input type="radio" value="4" id="checkboxFourInput_4" name="supplier_from" class="checkbox-gx">
						<label for="checkboxFourInput_4"></label>                        
                    </b>其他渠道
                </span>
				<span class="from-1">
                	<b class="checkboxFour">
						<input type="radio" value="3" id="checkboxFourInput_5" name="supplier_from" class="checkbox-gx">
						<label for="checkboxFourInput_5"></label>                        
                    </b>网络
                </span>
				<span class="from-1">
                	<b class="checkboxFour">
						<input type="radio" value="2" id="checkboxFourInput_6" name="supplier_from" class="checkbox-gx">
						<label for="checkboxFourInput_6"></label>                        
                    </b>朋友
                </span>
				<span class="from-1">
                	<b class="checkboxFour">
						<input type="radio" value="1" id="checkboxFourInput_7" name="supplier_from" class="checkbox-gx">
						<label for="checkboxFourInput_7"></label>
                    </b>亲友
                </span>
            </span>
            <b>*</b>信息来源
        </p>
        <p class="tjren mleft10">
            <span class="xxlyxz">
                <span class="from-1">
                	<b class="checkboxFour">
						<input type="radio" value="3" id="checkboxFourInput_1" name="supplier_visit_type" class="checkbox-gx">
						<label for="checkboxFourInput_1"></label>						
                    </b>没有联系
                </span>
				<span class="from-1">
                	<b class="checkboxFour">
						<input type="radio" value="2" id="checkboxFourInput_2" name="supplier_visit_type" class="checkbox-gx">
						<label for="checkboxFourInput_2"></label>						
                    </b>已介绍
                </span>
				<span class="from-1">
                	<b class="checkboxFour">
						<input type="radio" value="1" id="checkboxFourInput_3" name="supplier_visit_type" class="checkbox-gx">
						<label for="checkboxFourInput_3"></label>						
                    </b>已告知
                </span>
            </span>
            <b>*</b>联系与否
        </p>
    </div>
    <p id="commit" class="anniu gray_color"><a href="javascript:void(0);">提交</a></p>
</div>
<!----------------底部---------------------------->
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